Infectious Disease Prior Authorization Specialist

Overview Responsible for precertification of eligible prescription medications for inpatient and outpatient services, ensuring accurate documentation to meet insurer guidelines for medical necessity and payment for services. Models appropriate behavior in line with MLH Mission, Vision, and Values. What you will do Precertify prescription medications for inpatient and outpatient services. Verify medical documentation sufficiency for insurer guidelines. Review clinical information submitted by providers to evaluate necessity, appropriateness, and efficiency. Assist with patient assistance and grant coordination for outpatient pharmacy. Analyze information submitted by providers to make timely medical necessity review determinations. Verify physician orders for accuracy. Determine CPT, HCPCS and ICD-10 codes for proper prior authorization. Contact insurance companies and third‑party administrators to gather information. Collect, read, and interpret medical documentation for insurance reimbursement and charge capture. Serve as primary contact with physicians to collect clinical documentation. Establish and maintain rapport with providers, providing ongoing education on pre‑certification protocols. Communicate with Patient Access, Case Management, and other departments regarding contract guidelines and pre‑certification requirements. Research denials or problematic accounts as needed. Identify trends and root causes of issues, recommending process improvements. Education & Formal Training Requirements High School Diploma or equivalent. Licenses & Certifications Pharmacy Technician – Tennessee, Tennessee Board of Pharmacy. Certified Pharmacy Technician – Pharmacy Technician Certification Board. Certified Pharmacy Technician – ExCPT, National Healthcareer Association (preferred). Pharmacy Technician – Mississippi, Mississippi Board of Pharmacy (preferred). Knowledge, Skills and Abilities Basic understanding of prescription processing flow. Expertise in utilizing EMRs to document clinical criteria required for third‑party approval. Knowledge of medical terminology, drug nomenclature, symbols, and abbreviations in pharmacy practice. Strong attention to detail and critical thinking skills. Effective verbal and written communication with patients, associates, and health professionals. Problem‑solving ability and ability to recommend resolutions. Experience with a computerized healthcare information system. Familiarity with Microsoft Word. Excellent verbal and written communication skills. Supervision Provided by this Position No lead or supervisory responsibilities are assigned to this position. Physical Demands Physical activities include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion. Light work up to 25 lbs. of force occasionally and up to 10 lbs. of force frequently. Requires good balance, coordination, and close visual acuity. Work performed in general office or administrative conditions. #J-18808-Ljbffr 1200 MH-Memphis Hospitals